難治性胃潰瘍に関する知見補遺

Some Observations on Intractable Gastric Ulcers

　胃潰瘍は適切な保存的治療によって容易に縮小消失せしめることができる反面，また，しばしば再発しやすく，中には保存的治療に抵抗して長い経過をとるものも多いことも，よく知られている事実である．このことから，胃潰瘍は内科的疾患として保存的に治療するべきか，あるいは外科的疾患として積極的に切除するか，種々の見解が対立している．

　病理学的立場から，小出，村上らは，Ul-Ⅰ，Ⅱ，Ⅲなどの浅い方の潰瘍は別として，Ul-Ⅳの深い潰瘍は完治しにくいことを指摘したが，このことは現在広く支持されている．胃潰瘍の経過は，種種の精神的社会的な環境状況が動因として複雑にからみ合うので，一概に論ずることはできないが潰瘍そのものの性質によっても違うことは確かだといってよい．したがって，この点で，実際の潰瘍患者について，ある程度その潰瘍の運命を推測できるようなよりどころとなるものがあれば，臨床家にとっては大変都合がよいと思われる．そこで，臨床的な立場からも，難治性潰瘍の問題がUl-Ⅳの診断の問題とより合わせて論ぜられてきた．

Macroscopic observation of afixed specimen of a Ul-Ⅳ type gastric ulcer revealed a depressed area on the mucosal surface surrounding the base of the ulcer in a ring or belt-like fasion. The mucosal folds in this area were reduced in width, showing partly abrupt cessation and partly confluence. In a cross-sectional view of this area, the beginning of the mucosal depression corresponded with that of scar tissues, and the extent of the former fairly coincided with the latter. Contrariwise, it was also noted that the mucosal surfacewas elevated in a part around the base of the ulcer. Fibrosis was more manifest in the subserosa than in the submucosal layer. This scarring on the mucosal surface was remarkable in Ul-Ⅳ type ulcers, but not so distinct and of smaller extent in Ul-Ⅱ and Ⅲ type ulcers.

　By naming this scarring on the mucosal surface as the “sign” of ulcer scar, the authors have investigated gastrocamera pictures in cases of ulcer of the stomach he was able to follow up clinically. In about half of them this sign was recognized in gastrocamera pictures. These positive cases were then divided into recurring and non-recurring groups. Investigation of these two groups revealed that in recurring group this sign was predominantly positive, while in non-recurring group the sign was not distinct in more than the falf.

　If this sign is considered to be indicative of recurrence possibility of gastric ulcer, it is presumably impossible in more than half of gastric ulce patients to obtain radical cure by conservative treatment alone.